403761_Well Construction - GW1_20120319

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MAR 2 6AUL
ES`IDENTIAL WELL CONSTRUCTION RECORD
North Carolina Depart
WEL—eONTR'A,
1. WELL CONTRACTOR:
WILLIAM T. DUGGINS
Well-Gentracter-(1-ndivicfaat)-Name
ent of Environment and Natural Resources- Division of Water Quality
TOR CERTIFICATION # 3423
: d. TOP OF CASING IS ' FT. Above Land Surface*
*Top of casing terminated aUor below land surface may require
- a variance In accordance-with-15A-NCAe-2e -.0118.
TERRACON CONSULTANTS, INC
Well Contractor Company Name
5240 GREEN'S DAIRY ROAD
Street Address
RALEIGH NC 27605
City or Town State Zip Code
(919 ) 873-2211
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) EI-2011-PZdiet()
-
3. WELL USE (Check One Box) Monitoring tlMunicipal/Public D
Industrial/Commercial ❑ Agriculturai p Recovery D Injection D
Irrigation❑ Other D (li t u :)
DATE DRILLED_J2(. 2-
4.WELLLOCATJON:
EAGLE ISLAND
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Tip Code)
CITY: WILMINGTON
TOPOGRAPHIC / LAND SETTING:
❑Slope DValley
LATITUDE 36
LONGITUDE ?5
D
Flat
0
Ridge
e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount NIA
,9
g. WATER ZONES (depth):
Top 1 Bottom 7./ S Top Bottom
Top, Bottom Top Bottom
Top Bottom Top Bottom
Thickness)
7. CASING: Depth ,. Diem t Weight Material
. Top,14‹. Bottom '#1 Ft. PAC
: Top Bottom Ft.
Top Bottom Ft.
: 8. GROUT: Depth Material Method
Top ; ,� . Bottom Et. G-C fr+'1 F -G
Top Bottom Ft.
Top, Bottom Ft.
9. SCREEN: Depth Diameter Slot Size
Top lb Bottom ?'S Ft. 2, in: .1 In.
Top
COUNTY NEW HANG0i: Top
Bottom
Bottom
(check appropaate box)
Other fi �1 ipk l tom, T : '10• SAND/GRAVEL PACK:
Depth
"DMS OR
" DMS OR
'r + DD •
Top Bottom
Latitude/longitude source: MPS DTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
6. FACILITY (Name of the business where the well is located.)
Confined DisnosaLFacility NIA
Facility Narne Facility ID# (if applicable)
N/A
Street Address
EAGLE I 1 AND IJC
City or Town
ontactNap
�
riiii)hvi /Nevi
WILMIN('T(�N NC` 2Sag,
City or Town State Zip Code
251 4AD
State Zip Code
at g Ad ress
at g Ad ress
(2-)
Are code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
zs
b. DOES WELL REPLACE EXISTING WELL? YES Q NO cl
c. WATER LEVEL Below Top of Casing: (5 •"\ FT.
(Use "+'° if Above Top of Casing)
: Top Bottom
: 1 t. DRILLING LOG
: Top Bottom
b�
• Y
3 / 2-5-
5- 3
•
•
•
•
.
•
•
•
Ft.
Ft.
•
aterial
in. in.
in. in.
Size Material
Top (.- Bottom 2-5 Ft. 7i5C•1
Ft.
Ft.
Formation Description
SWv
LA y
C'
/
'Fbeci
gg,\-es,-"1
\c‘gk3c'''
‘„oc‘''‘)"sG
12. REMARKS:
• I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
: 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEAN PRO\i1p o TO THE WELL OWNER.
: SIGNAT
•
3112/12
E OF CEln'i IED WELL CONTRACTOR DATE
WILLIAM T. DUGGINS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev. 2/09